286804069-6-21-2022-21-AS-MCUA-CFLQYH-20220621123510

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286804069
Report Date: 06/21/2022
Date Signed: 06/21/2022 12:35:17 PM

Document Has Been Signed on 06/21/2022 12:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	INN ON VILLA LANE, THE		FACILITY NUMBER:	286804069
ADMINISTRATOR:	HUMPHREY, KIM		FACILITY TYPE:	740
ADDRESS:	3255 VILLA LANE		TELEPHONE:	(707) 252-3333
CITY:	NAPA	STATE: CA	ZIP CODE:	94588
CAPACITY:	86	CENSUS: 64	DATE:	06/21/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:58 AM
MET WITH:	Kim Humphrey (Administrator)		TIME COMPLETED:	12:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Cuadra, arrived unannounced to conduct a Pre-Licensing Inspection due to a change in ownership from Brookdale Napa and met with Kim Humphrey, Administrator. Hospice waiver requested with new application. Currently there are 42 assisted living residents. There are 6 residents on hospice. The facility does have a memory care unit currently with 22 residents. The facility is a two-story residence with forty-three bedrooms in the second floor which rooms # 225A and 225B are double occupant. The first floor with thirty-four bedrooms which rooms # 122A, 122B, 123A, 123B, 124A, 124B, 125A, 125B, 126A, 126B 127A, 127B 129A, 129B 137A and 137B are double occupant, Administrator’s office, Kitchen area, dining room area, living room, laundry room and waiting room area. The floor plans describes studios for single occupancy and they include a living area, small kitchen, closet and bathroom; One bedrooms above listed include a living area, bedroom with a closet, kitchen second closet and bathroom. The Fire Safety Inspection was conducted on 4/22/2022 fire clearance was granted by City of Napa Fire Prevention for 76 non-ambulatory and 10 bedridden residents on 4/22/2022. Bedridden rooms are located in assisted living room# 117, 118, 119, 120 and 121; In memory care unit rooms# 134, 136, 137, 138 and 139. Smoke detectors and carbon monoxide operate properly and fire extinguishers are properly charged as of 1/14/22. Facility has a sanitation station set up at the entrance to the facility in order to comply with Covid-19 precautions. Facility are screening staff or essential visitors for symptoms. The facility staff was observed wearing mask during the tour of main entrance, doors, common areas, dining rooms and kitchen area. Continues on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: INN ON VILLA LANE, THE	FACILITY NUMBER: 286804069
	VISIT DATE: 06/21/2022

NARRATIVE

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Continued from LIC809...

The facility was a comfortable temperature, equipment and supplies are not stored in the yard or areas used by residents were free from obstructions and was well lit. The walls, ceilings, paint, floors, windows, curtains, and doors were in good repair. Water temperature in resident's bathrooms measured between 112.6 and 119.6 degrees F which is within acceptable range of 105 to 120 degrees F. Rooms are free of odors, handrails, non-skid mats are present in showers, securely fastened grab bars in bathrooms. Bedrooms are equipped per regulation. There are supplies for personal hygiene and sufficient available for residents. There is a Memory Care Unit with delayed egress which was tested and functional. The signal system emergency pull cord is present and operational in each room. Cleaning products and other toxins are located in locked supply rooms. Medications were centrally stored and locked in the med-tech room. Residents handle their own cash resources. The kitchen was inspected and found to be clean and sanitary. Perishable and non-perishable foods were sufficient, with a 2 day supply of perishable foods, and a 7 day supply of non-perishable foods, as required. Required posters were observed including Covid19 related posters, Personal Rights, Ombudsman's poster and CCL Complaint. First aid kit was supplied. Emergency exiting plans, telephone numbers are posted. Activities and menus are posted. All exits have auditory alarms to alert staff when someone enters or exits the building. Last disaster drill was conducted on 2/24/22, fire drill on 5/18/22 and elopement drill on 4/29/22. Basic laundry equipment, working telephone, emergency lighting supplies, flashlights and batteries are present. The physical plant is consistent with the submitted facility sketch/floor plan. Resident and staff records are maintained. LPA confirmed with Applicant that if current residents choose to stay after Change of Ownership, a new Admission Agreement will need to be completed. Applicant understood. Component III Orientation was completed with Administrator. Pre-licensing passed and COMP III completed. Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulation. LPA will notify CAU of todays Pre-licensing inspection. Facility will operate with 24 hour staffing and Licensee will ensure sufficient staffing at all times. Corporation agrees to provide Liability Insurance upon license is issued. No deficiencies cited at todays inspection.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022

LIC809 (FAS) - (06/04)

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